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CHAPTER 6 Lecture Note PowerPoint Presentation Pharmacology and Older Adults Gerontological Nursing, Second Edition Patricia A. Tabloski Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. LEARNING OUTCOME 1 Explain the interaction between normal aging and responses to drug therapy in older people. Gerontological Nursing, Second Edition Patricia A. Tabloski Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Age-Related Changes that Increase Risk for Adverse Drug Events • Chronic disease • Polypharmacy • Physiological and adaptive responses Gerontological Nursing, Second Edition Patricia A. Tabloski Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Determinants of Physiological Response to Medications • Race • Ethnic • Genetic background Gerontological Nursing, Second Edition Patricia A. Tabloski Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Acute and Chronic Conditions May Alter • Pharmacokinetics (what the body does to the drug) • Pharmacodynamics (what the drug does to the body) Gerontological Nursing, Second Edition Patricia A. Tabloski Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Age-Related Changes • Decrease in body water (as much as 15%) and increase in body fat – Increased concentration of water-soluble drugs – More prolonged effects of fat-soluble drugs Gerontological Nursing, Second Edition Patricia A. Tabloski Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Age-Related Changes • Hepatic blood flow may be decreased by as much as 50% in individuals over 65 years – Increased toxicity with normal doses of “firstpass effect” drugs Less drug would be detoxified immediately by the liver Gerontological Nursing, Second Edition Patricia A. Tabloski Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Age-Related Changes • Decreases in serum albumin – Leads to altered binding capacity – May cause increased serum levels of the “free” or unbound proportion of protein-bound drugs – May result in toxic levels of highly proteinbound drugs because more unbound drug is available to produce its effects Gerontological Nursing, Second Edition Patricia A. Tabloski Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Kidneys Excrete Most Drugs • Considerable individual variation in the degree of decline of renal function Gerontological Nursing, Second Edition Patricia A. Tabloski Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Causes of Changes in Pharmacodynamics in the Older Person • Decreased number of receptors • Decreased receptor binding • Altered cellular response to the drugreceptor interaction Gerontological Nursing, Second Edition Patricia A. Tabloski Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. LEARNING OUTCOME 2 Identify principles of safe medication management with older persons in a variety of patient care settings. Gerontological Nursing, Second Edition Patricia A. Tabloski Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Pivotal Role of Nurse • Ensure drug therapy is effective for the person’s condition • Prevent, detect, or intervene as early as possible if the person develops adverse drug effects Gerontological Nursing, Second Edition Patricia A. Tabloski Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Common Inappropriate Drugs Administered to Older Adults • • • • Psychotropic agents Anti-inflammatory drugs Amitriptyline Iron supplements Gerontological Nursing, Second Edition Patricia A. Tabloski Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Inappropriate Conditions for Use of Antipsychotic Drugs • Wandering (To move about without a definite destination or purpose) • Poor self-care • Restlessness • Impaired memory • Anxiety • Depression (without psychotic features) • Insomnia Gerontological Nursing, Second Edition Patricia A. Tabloski Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Inappropriate Conditions for Use of Antipsychotic Drugs • • • • • • Unsociability Indifference to surroundings Fidgeting (the act of moving about restlessly) Nervousness Uncooperativeness Agitated behaviors that do not represent danger to the resident or others Gerontological Nursing, Second Edition Patricia A. Tabloski Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Residents Administered Antipsychotic, Anxiolytic, and Sedative-Hypnotic Drugs • Should receive gradual dose reductions at scheduled intervals Gerontological Nursing, Second Edition Patricia A. Tabloski Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Medication Regimen Review (MRR) • Required by Medicare • Involves a thorough evaluation of the medication regimen by a pharmacist, in collaboration with other members of the interdisciplinary team • Includes preventing, identifying, reporting, and resolving medication-related problems, medication errors, and other irregularities Gerontological Nursing, Second Edition Patricia A. Tabloski Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Nurse’s Role in Promoting Safe and Effective Medication Management • Assure the correct storage, preparation, and administration (including the five rights) in the institutional setting • Educate the patient and family concerning storage, preparation, and administration Gerontological Nursing, Second Edition Patricia A. Tabloski Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Nurse’s Role in Promoting Safe and Effective Medication Management • In the institutional setting, be aware of the legal aspects of medication delegation for the state in which he or she practices as well as the policies of the employing agency Gerontological Nursing, Second Edition Patricia A. Tabloski Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. LEARNING OUTCOME 3 Discuss measures to prevent and reduce polypharmacy in older patients. Gerontological Nursing, Second Edition Patricia A. Tabloski Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Older persons More Likely to Have Adverse Drug Reactions (ADRs) Related to • • • • Inappropriate drug or dosing Drug-drug interactions Polypharmacy Nonadherence Gerontological Nursing, Second Edition Patricia A. Tabloski Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Nursing Interventions • Can prevent the need for some medications • Can reduce the dose or length of drug therapy Gerontological Nursing, Second Edition Patricia A. Tabloski Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Polypharmacy • Definition: The prescription, administration, or use of more medications than are clinically indicated in a given patient • Examples • Medication that has no apparent indication • Continuing use of a medication after a condition has been resolved Gerontological Nursing, Second Edition Patricia A. Tabloski Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Polypharmacy • Use of a medication to treat the side effects of another medication • Use of an inappropriate dose • Use of duplicate medications because the same drug has been prescribed by more than one prescriber • Self-medicating with OTC medications or herbal remedies to treat the same condition Gerontological Nursing, Second Edition Patricia A. Tabloski Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Include in a Complete Drug History • • • • Vitamins OTC medications Dietary supplements Herbal remedies Gerontological Nursing, Second Edition Patricia A. Tabloski Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Indications for Reduced Dosages • Weight is less than average • Decreased liver or renal function • Experiencing exaggerated responses to drugs that may reflect toxic levels Gerontological Nursing, Second Edition Patricia A. Tabloski Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Indications for Drug Therapy • A specific diagnosis • Clearly documented symptom or condition to be treated • Avoid use of a drug to treat the side effects of another drug Gerontological Nursing, Second Edition Patricia A. Tabloski Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Unnecessary Drug Administration • Excessive dose (including duplicate therapy) • Excessive duration • Inadequate monitoring • Inadequate indications • Presence of adverse consequences that indicate the dose should be reduced or discontinued Gerontological Nursing, Second Edition Patricia A. Tabloski Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. LEARNING OUTCOME 4 Describe assessments to monitor older patients for adverse drug effects and polypharmacy. Gerontological Nursing, Second Edition Patricia A. Tabloski Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Assessment Parameters • Physiological and psychosocial status • Need for the drug • Risk of an adverse drug reaction Gerontological Nursing, Second Edition Patricia A. Tabloski Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. ADR Clues • Cognitive impairment (e.g., delirium, dementia, depression) • Loss of appetite, nausea • Weight loss • Falls Gerontological Nursing, Second Edition Patricia A. Tabloski Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Drugs that Can Cause Changes in Mood • • • • • • • Antihypertensives (e.g., beta-blockers) Antiparkinsonian agents Steroids NSAID Narcotic agents Antineoplastic agents Central nervous system (CNS) depressants • Psychotropics Gerontological Nursing, Second Edition Patricia A. Tabloski Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Causes of Falls in the Older Adult • • • • • Alterations in vision Balance Decreases in reaction time Orthostatic hypotension Decreased muscle strength Gerontological Nursing, Second Edition Patricia A. Tabloski Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Herbal Interactions with Medications • Elicit from patients any herbs, home remedies or dietary supplements that they take Gerontological Nursing, Second Edition Patricia A. Tabloski Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Medication Reconciliation • Indicated whenever an individual moves from one care setting to another • Verification (collection of the medication history) • Clarification (ensuring that the medications and doses are appropriate) • Reconciliation (documentation of changes in the orders) Gerontological Nursing, Second Edition Patricia A. Tabloski Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Review Each Drug for • • • • • Interactions with other drugs Interactions with herbal medicines Interactions with vitamins or foods Patient allergies Duplicate therapy – From more than one prescriber or from use of OTC medications containing the same or similar ingredients as prescribed medications Gerontological Nursing, Second Edition Patricia A. Tabloski Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Observe for • Known adverse effects of medication • General symptoms that might be drug related • Monitor laboratory results as appropriate Gerontological Nursing, Second Edition Patricia A. Tabloski Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. LEARNING OUTCOME 5 Use teaching and nursing interventions to promote compliance and adherence to the medication regimen. Gerontological Nursing, Second Edition Patricia A. Tabloski Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Medication Noncompliance Results in Considerable Costs to • • • • Patients Employer Health insurers Healthcare system Gerontological Nursing, Second Edition Patricia A. Tabloski Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Enhance Medication Compliance by • Reducing the impact of side effects through – Adequate intake of fiber and fluid intake can help to offset drug-induced constipation – Scheduling diuretic so that it does not interrupt sleep or activities important to the patient – Frequent intake of liquids or the use of lozenges to help with dry mouth caused by medications Gerontological Nursing, Second Edition Patricia A. Tabloski Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Drug Regimen Unassisted Grading Scale (DRUGS) • Used to assess an elderly person’s ability to take medications correctly • Employs four medication management tasks – Identification or showing the appropriate medications – Access, or opening the appropriate containers – Dosage, or taking out the correct number per dose – Timing, or demonstrating the timing of the doses Gerontological Nursing, Second Edition Patricia A. Tabloski Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Measures to Manage Medications Correctly • Simplifying the regimen if possible • Establishing a routine for taking medications • Scheduling medications at mealtime or in conjunction with other specific daily activities • Developing a method with the patient for remembering if he or she actually took the medication Gerontological Nursing, Second Edition Patricia A. Tabloski Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Measures to Manage Medications Correctly • Conducting a total assessment of all medication, including OTC and herbal preparations • Telephone reminders, computer-based reminders, or pill boxes Gerontological Nursing, Second Edition Patricia A. Tabloski Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Measures to Manage Medications Correctly • Obtain all of medications (prescription and OTC) from the same pharmacy; request no childproof packaging or caps • Determine any financial restraints; identify low-cost alternatives Gerontological Nursing, Second Edition Patricia A. Tabloski Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. LEARNING OUTCOME 6 Identify nonpharmacological therapies that may be useful as alternatives to medications. Gerontological Nursing, Second Edition Patricia A. Tabloski Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Medication Alternatives • Constipation – Increase bulk in diet – Avoid cheese – Encourage exercise – Ensure adequate fluid intake • Insomnia – Suggest warm milk – Adapt the environment to promote sleep – Avoid caffeinated drinks in the afternoon Gerontological Nursing, Second Edition Patricia A. Tabloski Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Medication Alternatives • “Heartburn” – Eat small, frequent meals – Stay in upright position for at least 30 minutes after taking medications • Pain – Use of distraction – Guided imagery – Positioning – Ice or heat Gerontological Nursing, Second Edition Patricia A. Tabloski Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. LEARNING OUTCOME 7 Discuss issues related to ensuring the safe use of drug therapy by the older person. Gerontological Nursing, Second Edition Patricia A. Tabloski Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Drug Therapy Issues • Healthcare fraud ( is a crime. It's committed when a dishonest provider or consumer intentionally submits, or causes someone else to submit, false or misleading information for use in determining the amount of health care benefits payable. • • • • • ) Medication costs Internet pharmacies’ legitimacy Sharing others’ medications Use of imported medications Use of outdated medications Gerontological Nursing, Second Edition Patricia A. Tabloski Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.